Case Report

Acute Perforated appendicitis with leukopenic presentation

Abstract

Most patients with appendicitis had elevated white blood cell count. It is rarely seen with leukopenic presentation in acute appendicitis. Physicians in the emergency department easily miss these cases that had normal white blood cell count and leukopenic presentation. We presented a case of a 38-year-old man who had Right lower quadrant abdominal pain with fever. White blood cell count was only 1800/uL. Computed tomography showed thickening with fluid contained in the lumen of distended appendix, and emergent appendectomy was done. Accurate diagnosis of acute appendicitis is still based on the clinical history and physical examination adjuvant with imaging studies.

A 38-year-old man with anorexia complained of Epigastric pain for 1 day, and the pain migrated to the right lower quadrant when he arrived our emergency department (ED). He was healthy before presentation and had no systemic disease without current medication. Vital signs included body temperature of 40.5?C, respiratory rate of 20 breaths per minute, pulse rate of 141 beats per minute, and blood pressure of 162/83 mm Hg. Physical examination revealed right lower quadrant abdominal tender with localized muscle guarding, and positive obturator sign. Laboratory data included white blood cell count of 1800/uL, neutrophil of 55%, band of 1%, hemoglobin of 16.9 g/dL, platelet count of 133000/uL, amylase of 75 U/L, and aspartate transaminase of 32 IU/L. Based on the clinical history and physical examinations, typical appendicitis was the likely diagnosis. Because the WBC count was 1800/uL, we eventually arranged for a computed tomography (CT) scan to identify the disease and to find out any other possible disease before surgical intervention. Computed tomography revealed wall thickening with fluid contained in the lumen of distended appendix and evidence of pericecal fat stranding, indicating acute appendicitis (Figs. 1 and 2). Gangrenous change of appendix with perforation was noted by emergent laparotomy, and pathologic confirmation was done. After appendectomy, the fever subsided and WBC count returned within the reference range (7700/uL).

diagnosis of appendicitis always relies on detailed History taking and physical examinations. Some inflammatory parameters could be valuable in the diagnosis of acute

Fig. 1 Wall thickening with fluid contained in the lumen of distended appendix (black arrow) and evidence of pericecal fat stranding, indicating acute perforated appendicitis (coronal Section).

appendicitis [1]. Inevitably, elevated WBC count raises the concern of higher possibilities of diagnosing appendicitis. There have been that analyzed the relationship between leukocytosis and acute appendicitis [2-6]. It is well known that a single WBC count is neither sensitive nor specific in the diagnosis of appendicitis [7]. In the past, Gaidarski et al

[8] reported leukopenic presentation in acute appendicitis (2.6% of 3821 patients).

Because acute appendicitis is the very commonly seen in the ED worldwide, physicians should pay more attention to those patients who complained of right lower abdominal pain without any abnormal laboratory finding. The study of Goodman et al [9] revealed that 79% of patients with appendicitis had an elevated preoperative WBC count and 88% patients had a neutrophil-lymphocyte ratio of 3.5:1 or higher. Clinicians should be wary on relying on either elevated WBC count or temperature as an indicator of the presence of appendicitis [10]. Clinical history and physical examinations are always the foundation in the diagnosis of appendicitis because that single WBC count is neither sensitive nor specific in the diagnosis of appendicitis [7]. Perforated appendicitis increases the complication rates after appendectomy such as that for abscess formation,

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Fig. 2 Sausage-like appearance of engorged appendicitis in a sagittal view (black arrow).

reoperation, and intra-abdominal sepsis [11]. The propor- tion of gangrenous and perforated appendicitis in the patients with a normal WBC count is the same as in the patients with an elevated WBC count [12]. Thus, WBC count is not a good predictor of the severity of appendicitis. In some cases, maybe we can take advantage of CT scan in the diagnosis of acute appendicitis because it is more sensitive and specific than other laboratory investigations. Helical CT scan has 92% sensitivity, 97% specificity, and 96% accuracy in diagnosing appendicitis [13]. Leukocy- tosis could not be used in the selection of patients for surgery because the sensitivity rate of leukocytosis in acute appendicitis is about 68% to 88% in the previous studies [2-6]. Acute appendicitis revealed 97.4% leukocytosis and normal leukocyte count [8]. In this case, acute perforated appendicitis with leukopenic presentation is very rare. Nevertheless, the accurate diagnosis of acute appendicitis is still based on the clinical history and physical examination adjuvant with imaging studies.

Yen-Yi Feng MD Department of Emergency Medicine Mackay Memorial Hospital

Taipei 10449, Taiwan

Yen-Chun Lai MD Department of Anesthesiology Mackay Memorial Hospital Taipei 10449, Taiwan

Yu-Jang Su MD Department of Emergency Medicine Mackay Memorial Hospital

Taipei 10449, Taiwan Mackay Medicine

Nursing and Management College

Taipei 112, Taiwan E-mail address: [email protected]

Wen-Han Chang PhD Department of Emergency Medicine Mackay Memorial Hospital

Taipei 10449, Taiwan

doi:10.1016/j.ajem.2007.11.018

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